Mental Hospitals in “One Flew Over the Cuckoo’s Nest”

I started this blog by writing about very popular recent films, like Twilight and The Girl with the Dragon Tattoo. However, my last post focused on the classic film A Clockwork Orange, and I was surprised by how many hits I got. So this time, let’s tackle one of the giants: One Flew Over the Cuckoo’s Nest. Just how realistic is this movie when it comes to the general rules, layout, and procedures in a mental hospital? First let me just get this statement out: As wonderful as the film of Cuckoo is, the book is even better. I said this before, for Dragon Tattoo and for A Clockwork Orange. Notice that I did not say this for Twilight, as I personally believe those books make you dumber for reading them.

But this blog is about the movie. When I was in grad school, I worked as a Psychiatric Technician at the county mental hospital. If you’re not familiar with that job, it’s sort of a combination of three major duties. First, I was assigned between two and five patients each day, and I would interact with them, play games, talk about their needs, eat with them, etc. At the end of my shift, I’d write a report of everything in each patient's record. Part 2 was to complete intake interviews with new patients and orient them to the hospital (give a tour, explain the rules). Finally, I was sort of an ad-hoc security guard, in case any of the patients decided to escape (which only happened once while I was there) or attack (which happened pretty frequently).

The basics

Cuckoo’s Nest is basically about a man named McMurphy who decided that life in a mental hospital would be easier than life in prison, so he decides to “fake” being “crazy” to be moved. The rest of the movie is about his interactions with the other patients and with the villain of the story, Nurse Ratched. When I worked at the hospital, we did occasionally get prisoners who had been moved, so that part is correct. Most prisons don’t really have the facilities necessary to help people with mental issues. However, a big difference between the movie and reality is that while I worked there, the hospital only got two or three people from the prison, and they had attempted suicide.

McMurphy goes through an interview upon arrival, which is also pretty realistic. My job during this aspect of my duties was to fill out a two-page form that was partially patient responses to questions (like, “What day is it?”, “What do you hope to get out of your hospital stay?”, and “Are you planning to escape?”), and partially my observations of the person during the interview (such as whether he/she was cooperative or showed verbal symptoms of schizophrenia). I also got to do a strip search for each person (not my favorite part), checking for any cuts, bruises, or contraband the person might be trying to sneak in.

The architecture of the hospital

Cuckoo’s Nest was filmed in an actual mental hospital, which of course makes this aspect of it very realistic. The hospital used was Oregon State Hospital. One purpose of the book and movie was to highlight the terrible conditions of mental hospitals of the time, especially in terms of these huge “mansion” type buildings. Why are all these old hospitals so frikken’ big? The answer is the Kirkbride Plan.

In the mid-1900s, there weren’t a lot of good pharmaceutical treatments for mental illness, so the number of patients in need of a place to live was massive. While early mental hospitals couldn’t handle the numbers and treated people extremely badly, a trend called “Moral Management” called for these people to be treated with the care and respect that everyone deserves. So the Kirkbride Plan for mental hospitals was created. The Plan called for spacious, clean buildings that provided fresh air, sunlight, gardens or courtyards, and comfortable rooms for the patients. Oregon State Hospital was built using the Kirkbride plan, so in this way, the movie shows a pretty representative physical structure. What’s interesting about the Kirkbride Plan and Moral Management was not just the physical expectations, however; patients were also supposed to be treated with a high level of ethical respect. This is where Cuckoo’s Nest—and Oregon State Hospital—both get interesting.

When I was trained to work in the county mental hospital back in the late 1990s, ethics were a big deal. Respect confidentiality, respect patient needs, respect patient safety first and foremost. Oregon State Hospital (the real one) is actually pretty infamous for treating the patients fairly terribly. Perhaps most well-known is that in 2004, a search of the hospital grounds unearthed a total of 3500 cremated bodies of former patients who had been stuck inside copper barrels over the past 100 years of the hospital’s existence. Only about half of the hospital is currently being used, because a lot of the original buildings had to be closed down due to things like leaking roofs, asbestos, and lead paint.

In the movie, lack of concern about patient safety is an interesting theme. The guards are portrayed as easily corruptible simpletons who can be bribed with a bottle of booze. (While I worked at my hospital, I guess some people might have thought I was a simpleton, but the patients certainly didn’t have access to loads of cash or entire bottles of booze). Interestingly the guards are also depicted in a somewhat racist fashion as they are all sort of “stereotypical” African Americans, but unfortunately at the time, many undesirable jobs were “assigned” to citizens with fewer options (kind of like undocumented workers today who are stuck working in dangerous meat packing plants). Everyone who works at the hospital in the movie has decided that ECT (electric shock therapy) should be used to punish unruly patients, instead of as actual treatment for schizophrenia (which used to be common) or depression (which is still fairly common).

Of course, the highlight of Cuckoo’s Nest is the fascinating interaction between McMurphy and Nurse Ratched. She has complete control over his life, something with which he struggles mightily. He is surprised to discover that it is up to her and the psychiatrists whether he is “released,” and that he doesn’t just have to wait until his prison sentence is up. This aspect of the movie is true. If a patient volunteers to reside in the hospital, he or she can check out at any time. But if a patient is assigned to the hospital by a judge or referred there by somewhere like a prison, the staff can decide whether to release that person based on his/her possible danger to self or danger to others.

But what about the terrible way Ratched treats McMurphy? I’ve met a lot of psychiatrists and I observed dozens of people while I worked at the hospital. Sure, it’s possible that somewhere, there’s an evil person corrupting his or her patients. But I think this must be highly unlikely. From my experience, people who work in the field of mental health enter this field not because they want to get rich, or because they want to hold power over others, or because they want to conduct weird experiments. They get into the field of mental health because they want to help people.

This conclusion isn’t particularly dramatic, and it won’t make for good cinema. Cuckoo’s Nest is realistic in some ways, and it was a hugely important movie for the time, because it helped bring attention to some hospitals with unethical practices or unsafe living conditions. Both the book and the movie are insightful views into societal problems such as stereotypes about people who have mental disorders. But the film is largely out of date in terms of depicting hospital staff as manipulative or evil. From what I saw when I worked in a similar institution, mental hospitals are a calm, healing environments—as they should be.

I am an attorney who represents the alleged incapacitated person in mental health hearings/ect hearings. I have seen my share of mental hospitals one would not like to be incarcerated in - most people are simply drugged to the gills. Most staff are not evil but simply incompetent although I have certainly met some Nurse Ratchet-lite mental health workers.

Thanks for reading & posting. That's disappointing to hear. My experience was pretty positive. I think there are more good people in the field than bad. You probably get a lot of "all lawyers are bad" junk -- I'm guessing it's the same thing.

I am a psychology student. Before I decided to go back to school and obtain my Ph.D. I worked in adult foster care homes for the mentally ill for ten years. I worked with patients from every diagnosis possible. I agree fully to your comment that the staff that work in these homes are incompetent to do so.

As a direct care worker you receive minimal training about the mental disorders. You basically cover the names of the disorders. You trained in CPR and first aid and taught how to protect yourself. You are not taught the how's and why's of the disorder or how to deal with the different symptoms of the disorders.

I feel our mental health system is broken, it can be fixed. I got tired of not being able to help my patients to the extent that I wanted to. I didn't have a degree to do so. On the other hand I spent everyday with my patients. They are people, they are not stupid and they know what is going on. They have a voice to be heard that is often ignored. In most cases I knew more about the person than their psychiatrist.

The typical trip to the see the psychiatrist was about 5 to 10 minutes if you were lucky in the room. The only thing happened were questions, "How are you, how are you feeling, are you having any negative thoughts?" If the patient replied they were doing well the appointment was over. Occasionally we were asked questions. There were times when I spoke up about things that I observed but they were disqualified because who was I, just the worker.

I believe that still today these people are portrayed different and worthless, and that the care they receive is not the best due to stigmas and not having properly trained personnel working with the patients.

My life goal is to become a psychologist and try my hardest to make a positive impact on the mental health community.

Thanks for your comment. I believe that many, many people who work in institutions are well trained and well meaning. However, it's impossible for that to be the case with everyone (and that would be true for any profession).

I am a psychologist who has worked in one of those hospitals for 43 years. When I first saw the movie, it was so realistic it was almost the first movie I ever walked out of in my life. I stayed and was glad I did. Back then it was a very realistic portrayal of how psychiatric hospitals operated. Today, most, although not all I am sure, are modernized, well functioning places for up to date treatment. I don't know where the attrney is from, but most of the psychiatric facilities have come a long way since the 1970s.

I agree with you; while I think hospitals in the 1970s had a lot of problems, most of them now are highly respectable places. Of course, it's possible that some are still below standard or simply have a sense of being overwhelmed -- but I do believe most people who work there are there for the right reasons. Thanks for reading & posting!

Totally disagree. I think this kind of thinking has more to do with the idolatry of the here and now and the refraction of reality through the eyes of people who either desire progress or profit existentially from the delusion of progress in a field that is as riddled with quackery and barbarism as it ever was. Human beings generally, apart from those schooled at the university of bitter experience, have a tendency to think things are better regardless, because they are part of this current generation, and find it more emotionally satisfying to sit back in smug judgement upon the past rather than cast a critical eye on the present.

Of course, future generations will look back on ours and see flaws that we did not see. However, your argument that the current generation can not also see progress that's been made doesn't seem to make much sense to me. I think you would be hard pressed to find any professionals in the field who would not agree that mental hospitals of today are better than they were 50, 30, or even 10 years ago.

I was under the thumb of a Nurse Ratched type in 2010 as a private hospital inpatient. She even looked how I imagine Louise Fletcher would look if she smoked two packs a day. Gail was the fake name she used, and we called her Scarecrow Gail. Her job was to spend two minutes twice a day meeting with each patient and quickly and effectively making them feel as horrible as possible. She knew I was having problems with issues regarding my sexual identity, and every time I met with her she asked me, "How are you feeling about your homo..." She never once finished the word. She basically spent a couple minutes poking you with a sharp psychological stick, then got up and left you to bawl your eyes out. Finally some other patients explained to me that she was just purposefully being hateful to see if any of us were actually capable of physically attacking someone (McMurphy style, I suppose.) After that I did everything I could to just avoid meeting with her. She would sometimes be in charge of a group or activity and everyone would refuse to go. She also met with me for my discharge and did the same thing before I was allowed to leave - it was absolutely nightmarish.

That is a horrible story, for several reasons. First, I don't know why she would be using a fake name; I've never heard of that in this context. Second, I'm extremely disappointed that she was not supportive in whatever you discovered about your sexual identity. Current APA standards (and my personal beliefs) are that all sexual identities are valid (except of course coercive ones like pedophilia), and that no sexual minorities should be "treated" unless they want that treatment. I myself identify as bisexual, and I do a lot of research on prejudice against sexual minorities. It sounds like you had a really bad experience, and even though I really am not qualified to make the following statement, I'd like to apologize on behalf of the entire community of psychologists!

Hopefully she is no longer working there.

Thanks again for posting (I assume you are the same Stacy who commented on the "Clockwork" post).

(Yes, I am the same Stacy.) The entire hospital staff except for psychiatrists used fake first names only and told us so. They did explain their reasoning behind it - they said it was for their safety. Thanks for the reply -

In the hospitals yes I do believe the staff are well trained. However, in the adult foster care homes, where the training you receive is a two week course from Community Mental Health, the staff are not well trained. The very basics of mental illnesses are covered. There is a one day section on medications. Staff in the homes are not prepared to be passing medications. Working in the homes I had to teach myself,

Thanks for your comment. I haven't ever had interaction with the foster care system, so I really can't respond to that. But, if I understand you correctly that you work in the foster care system, thanks for your service to an area that needs wonderful people!

Here is a related music video - haunting photos of the hundred years Essondale Mental Hospital existed . . . yes, there are defnitely aspects of the Cuckoo's Nest yet also a sense of a real community. www.youtube.com/watch?v=_KVkWnamqtk

Thanks for the feedback. The old hospital is closed now and used for movie and TV sets such as episodes of the X Files. There's an eerie atmosphere still, until they tear everything down for new condo developments.

Don't agree with much in this article. These places aren't even hospitals. They bare only a cosmetic relation to real hospitals, not a substantial one. They are penitentiaries, albeit mystified by the idiom, architecture and symbology of real hospitals and real medical practice.

The author takes issue with the portrayal of the staff. There is some truth in this. Hollywood's iconography of evil rarely affords a true understanding of evil, and does little to train our eyes to perceive it in the real world and the various forms it takes. Like a Hydra, it is a monster with many faces.

As Camus said in the Plague; "The evil that is in the world almost always comes from ignorance." Nevertheless, there is much truth in the portrayal of evil and life on the psychiatric ward in this film. What this film shows is what conflict does to people. In every man, there is a struggle between his lower and higher instincts for supremacy. In situations of conflict, the latter come to the fore. The film is actually quite an accurate portrayal of the psychological underpinnings of conflictual interpersonal relations, and conflict will always be found where people are deprived of their liberty without having committed a crime and subjected to the whole gamut of degrading treatment that characterizes life on a psychiatric ward.

The people who seek to absolve the psychiatrists and nurses of their crimes against humanity (that is, those who violate the integrity of the body and the sanctity of the spirit with their pernicious nostrums forcibly imposed upon the powerless patient) have a tendency to claim that most simply want to help and act under the guidance of a pure nature, completing ignoring the often adversarial nature of the relationship between staff and patient.

I think you really misunderstood my stance on this issue. I acknowledge and agree with you that some mental hospitals in the past used unethical policies and procedures. One of the reasons "Cuckoo" is so famous is because is pointed these out. However, as someone who has worked in a mental hospital and as someone with a doctorate in psychology, I can tell you that today, most mental hospitals are extremely professionally run, with competent staff who care about their patients. The vast, vast majority of people who go into the field of psychology want to help others, and do that to the best of their ability.

As a former patient in a psychiatric ward in 2010, I can definitely tell a feeling of "superiority" in the staff with the patients. Yes, there are bad and good staff, but it's not the psychological treatment, but the manners from a patient to a staff member. The nurses would place a cloth over the chairs because the chairs we sat on were obviously contaminated. They do still place guards over windows and lock the elevators. I actually felt the movie portrayed a very positive view from the protagonist view and how a little humanity from someone could have a huge positive impact on a person with a disability instead of treating them as "insane" or "crazy" but as a person with a disability instead of their disability is "wrong" for the society we live in. Also, about the drugs, I was given a medication without no warning of the side effect and even at my hospitalization, I didn't know what the real side effects were. To be honest, it's not the hospital that saved my life, but going to private treatment. I wish there were better mental clinics, and hope to do that when I finish school.

Thanks for reading and for posting. As I've said above, of course there will be variance in individual hospitals and staff members. I'm sorry to hear that your experience was not positive. I do need to defend the security measures taken by hospitals (such as guards and locked wards); these are necessary for the safety of the patients and the staff. There were many times when I worked at the hospital when patients tried to either escape or assault either another patient or a staff member.

Either way, I'm glad you were eventually able to find the help you needed. I also hope that you can help to continue making improvements in the field of mental health!

I was in a psychiatric ward in the UK in 2013 and, though the film naturally takes some artistic liberties, it still rang very true to life to me. The attitude of staff is very variable. Some feel that they are carers, but some still behave like they are prison guards.

Thanks for your post. I would love to learn more about the mental health policies in the UK. I agree with you that the staff may seems like prison guards in some ways. For me, that was because we needed to keep security in mind all the time -- but that was for safety purposes. And, I'm sure some staff are better than others, which would be true of any institution.

I'm wondering if you saw a movie about a mental institution and the doctor that ran it. He got a young woman pregnant, had the baby delivered in the hospital and left the child there to grow up. the institution was taken over by the state and a young doctor was put in charge to evaluate the patients. He met the now young man who had only known the mentally disabled, so everything he did was a mimic of the patients. The doctor discovered his history and brought the boy home to live with him and his new wife until one day he moved on, he had to leave his past behind and it was the end on the movie. Yes I know, grasping at straws here.
jw

Hi - sorry it took a while to respond; I haven't posted anything here for a while, so I wasn't checking for comments. Unfortunately I have not seen the movie you describe - but it sounds very interesting!